A.Y.

2022-2023

CON
Wesleyan University Philippines
2022-2023
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

PERFORMANCE EVALUATION TOOL

NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)

DIRECTIONS: DONNING AND DOFFING OF PERSONAL PROTECTIVE

● The evaluation toolEQUIPMENT
will be discussed by the clinical instructor/s.
● During the discussion, the instructor/s may demonstrate the procedures or may use
video viewing for students’ orientation.
● The students should be given sufficient time to prepare for the return demonstration.
● The students will do the return demonstration based on the checklist given.
● The following rating scale shall be used in grading student’s performance:

DONE - able to perform

Perform the procedure safely and accurately in a very consistent and
independent manner without supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on client while giving care

NOT DONE - unable to perform

Unable to perform procedure even under close supervision of guidance
Require continuous, supportive and directive cues
Takes longer time to complete the procedure.

Performs in unskilled manner

● At the end of each laboratory session, the instructor/s will give remarks based on the
student’s performance in accordance to the procedures indicated.
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

PERFORMANCE EVALUATION TOOL

NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)
NAME OF STUDENT: _____________________
Block #______

PROCEDURE: DONNING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT

(GLOVES, GOWN, MASK, EYEWEAR)

DONE NOT DONE

1 The patient and staff will remain free from exposure to
potentially infectious microorganisms
2, GLOVES:
3, ● To protect the hands when likely to handle any
body substances (blood, urine, feces, sputum and
4,
non-intact skin)
● Reduces the likelihood of transmitting the health
workers’ own endogenous microorganisms to
individuals receiving care
● Reduces the chance of transmitting microorganisms
from one client to another

5 GOWN:
● Worn by health workers during procedures when
uniform is likely to become soiled

6 FACE MASKS
● To reduce the risk for transmission or organisms
by the droplet contact and airborne routes and by
splatters of body substances

7 EYE WEAR (goggles, glasses, or face shields)

● Protects mucous membranes of the eyes from
body substances may splatter the face
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

ASSESSMENT

1 Assess the situation to determine the necessity for

PPE. In addition, check the patient’s chart for
information about a suspected or diagnosed infection
or communicable disease.
2 Determine the possibility of exposure to blood and
body fluids and identify the necessary equipment to
prevent exposure.

PROCEDURE RATIONALE
1 Check medical record and
nursing care plan for type of
precautions and review
precautions in infection
control manual
2 Plan nursing activities before
entering patient’s room, as
well as gathering all the
equipment as follows:
● Gloves
● Mask
● Impervious Gown
● Protective eyewear
3 Provide instruction about
precautions to patient, family
members, and visitors.
4 Perform hand hygiene
GOWNING
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

5 Pick up a clean gown and This will prevent cross

allow it to unfold in front of contamination between
you without allowing it to the soiled and clean
touch any area soiled with areas.
body substances
6 Slide the arms and hands
through the sleeves
7 Fasten the ties at the neck to
keep the gown in place
8 Overlap the gown at the back
as much as possible, and
fasten the waist ties or belt

WEARING FACEMASK AND EYEWEAR

9 Locate the top edge of the

mask. The mask usually has
a narrow strip along the edge
10 Hold the mask by the top two
strings or loops
11 Place the upper edge of the
mask over the bridge of the
nose, and the upper ties at
the back of the head or
secure the loops around the
ears
13 If glasses are worn, fit the
upper edge of the mask
under the glasses
DONNING GLOVES

14 Open the package by

grasping the edge of the
cover
15 Using your dominant hand
grasp the opposite glove and
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

slide your nondominant hand

inside the glove, leaving the
cuff folded inside out.
16 Using your gloved
nondominant hand slide it
inside the folded cuff of the
other glove and slide your
dominant hand inside it.
17 Secure your fingers now until
they are properly placed
inside the glove
18 If wearing a gown, pull the
gloves up to cover the cuffs
of the gown. If not wearing a
gown, pull the gloves up to
cover the wrists
REMOVING PPE

19 Remove PPE: except for Proper removal

respirator, remove PPE at
the door-way or in an
anteroom
20 If a protective gown has been
tied in front of the body at the
waistline, untie waist strings
before removing gloves.
prevents contact with
and the spread of
microorganisms.
Removing respirator
outside the patient’s
room prevents contact
with airborne
microorganisms
Outside front of
equipment is
considered
contaminated. The
inside, outside back,
ties on head and back
are considered clean
which are areas of PPE
that are not likely to
have been contact with
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

infectious organisms.
Front of gown including
waist strings, are
contaminated. If tied in
front of body, the ties
must be untied before
removing gloves.
21 Grasp the outside of one Ungloved hand is clean
glove with the opposite and should not touch
gloved hand and peel off, the contaminated areas
turning the glove inside out
as you pull it off. Hold the
removed glove in the
remaining gloved hand.
22 Slide fingers of ungloved
hand under the remaining
glove at wrist, taking care not
to touch the outer surface of
the glove.
23 Peel off the glove over the
first glove, containing the one
glove. Discard in appropriate
container
24 Perform hand hygiene
25 To remove the goggles or Outside of goggles or
eye protective equipment: face shield is
handle by the headband or contaminated. Handling
earpieces by headband or
earpieces and lifting
26 Life away from the face,
away from face
place in designated
prevents transmission
receptacle for reprocessing
of microorganisms.
or in an appropriate waste
Proper disposal
container.
prevents transmission
of microorganisms
 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

27 To remove gown: Unfasten Gown front and sleeves

ties, if at the neck and back. are contaminated.
Handling by headband
28 Allow the gown to fall away
or earpieces and lifting
from shoulders. Touching
away from face
only the inside of the gown,
prevents transmission
pull away from the torso.
of microorganisms.
29 Keeping hands on the inner Proper disposal
surface of the gown, pull prevents transmission
gown from arms. Turn gown of microorganisms
inside out then fold or roll into
a bundle and discard.
30 To remove mask or Front of mask or
respirator: Grasp the neck respirator is
ties or elastic, the top ties or contaminated. Not
elastic and remove. touching the front of the
mask and disposing the
31 Take care to avoid touching
mask properly prevent
front of mask or respirator.
transmission of
Discard in a waste container.
microorganisms
32 Preform hand hygiene
immediately after removing
all PPE.

TOTAL SCORE=41pts

REMARKS:__________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Expected level of performance
25 to 32 items done: PASS
Below 24 items done: Repeat Procedure to PASS

Student’s Signature:_______________ Instructor’ Signature________________

 Wesleyan University –Philippines
Mabini Extension, Cabanatuan City 3100
College of Nursing
Tel. No. 044-463-2162/2074; Fax No. 463-0596 local 126

Date:_____ Date:__________